Ministry of Health of Ukraine

Ukrainian Medical stomatological Academy

It is ratified
On meeting department
Of accident aid and military medicine
«___»_____________20___г.
Protocol №______
Manager of department
DMSc., assistant professor _____________ К.Shepitko

METHODICAL INSTRUCTION
FOR INDEPENDENT WORK OF STUDENTS
DURING PREPARATIONS FOR THE PRACTICAL LESSON

Educational discipline «Emergency First Aid»

Module № 1 Emergency and Combat First Aid
Topic 2 Hemorrhages and Modes of Its Arrest

Bleeding and methods of stopping it.

Lesson 4 Causesand symptoms of internalbleeding.
Collapse, shock
Сourse ІІ
Foreing students training dentistry
Faculty

Training of specialists of the second (master) level of higher of education

(название уровня высшего образования)
Areas of knowledge _______ 22 «Health protection»_________
(шифр и название области знаний)
Specialty ________222 «Medicine»________
(код и наименование специальности)

Poltava 2019
 Relevance of the topic:
Bleeding from the main vessels is the most dangerous for human life, but bleeding from
the cavities of the human body becomes even more dangerous because they are not
visible and a lot of blood is lost (massive bleeding). Bleeding can occur with injuries, as
well as from the respiratory tract, stomach, intestines, and uterus. In everyday life, other
forms of anemia often occur, such as collapse caused by temporary functional
insufficiency of cardiac activity, and shock associated mainly with bleeding of the body,
significant damage to internal organs or the musculoskeletal system, nerve trunks and is
accompanied by depletion of the neuro-humoral regulation of cardiovascular system,
which leads to a sharp drop in blood pressure, vasodilation and heart failure. Shock is a
life-threatening condition. Properly performed rescue operations at the stage of DMP is
the key to further successful treatment of shock.
Specific objectives:
The student should be able to provide premedical care for internal bleeding; recognize
collapse and shock and provide medical care; provide medical care for bleeding from
wounds of the limbs, nose, mouth, ears, amputation of the limb; maintain temperature
balance.
Basic knowledge, skills needed to study the topic (interdisciplinary integration):
Name of previous disciplines Acquired skills
1. human anatomy Anatomy of the head and neck, anatomy of
the chest, abdomen, pelvis and limbs.
Anatomy of the vascular system.
2. Normal physiology Physiological basis of the functioning of
the respiratory system, vascular system.

Tasks for independent work in preparation for the lesson and in the lesson:
1. Causes and signs of external bleeding.
2.Dental care for internal bleeding.
3. The concept of collapse and shock, the causes of their occurrence, recognition and
provision of medical care.
4. Specific cases: bleeding from wounds of the limbs, nose, mouth, ears, amputation of the
limb.
5. Blood substitutes and means for their intravenous administration at the stage of medical
care.
6. Maintaining temperature balance.

The list of basic terms, parameters, characteristics that a student must learn in
preparation for the lesson:
Term Definition
1. Bleeding leakage of blood from damaged blood
vessels.

2. Internal bleeding characterized by leakage of blood from

damaged vessels into cavities, organs and
 surrounding tissues.

3. Internal bleeding is characterized by: - pallor of the skin;

  - frequent weak pulse; - frequent
breathing;
  - nausea, vomiting, thirst;
  - tachycardia, lowering blood pressure;
  - a decrease in the level of hemoglobin,
red blood cells in a blood test
  - secretion of blood with feces, urine,
food.

4.Wound this is a violation of the integrity of the

skin or mucous membrane with possible
damage to surrounding tissues.

5. Chemical methods of stopping bleeding chemicals that cause vasospasm

(adrenaline) Sol. adrenalini hyfrochloridi
0.1% - 1 ml, (norepinephrine) Sol. nor
adrenalini 0.2% - 1 ml. Vasoconstriction
causes a drug such as ephedrine (Sol.
Ephedrine hyfrochloridi 5% - 1ml), but
drugs like naphthyzine 10 ml, sanorin,
galazolin, isadrine, novodrin, euspiran
narrow the blood vessels in inflammatory
processes and do not cause bleeding to
stop. Calcium chloride (Sol. Calcii
chloride 10% 10 ml), hemophobin (Sol.
Haemophobini - 150 ml), fibrinogen (Sol.
Fibrinogeni 250, 500 ml) take part in the
creation of a convolution and stop bleeding.
Hemophobin and fibrinogen are released
in bottles, obtained from the blood plasma
of the donor.

Theoretical questions for the lesson:

 
1. Cause and signs of internal bleeding.
2.Dental care for internal bleeding.
3. The concept of collapse and shock, the causes of their occurrence, recognition and
provision of medical care.

Practical work (tasks) that are performed in class.

1. To master the technique of applying a GARDEN tourniquet (turnstile), an Israeli

compression bandage, using powdery, granule-like hemostasis.
2. Determine blood loss according to the victim’s weight, shock index according to the
pulse and blood pressure.
3. To help with fainting, collapse, shock.

The contents of the topic:

Causes and signs of internal bleeding.

Bleeding from major vessels the most dangerous to human life, but bleeding in the cavity
of the human body be even more dangerous that they are not visible and they lost a lot of
blood (massive bleeding). Bleeding may be for injuries, as well as from the respiratory
tract, stomach, intestines, uterus.

Pulmonary hemorrhage. The main cause of bleeding: tuberculosis (60%), suppurative

disease (bronchiectasis). The inflammatory process in the lung deform the vessels,
change their wall, appears ulcer and bleeding. Broken system forming clots. When
profuse bleeding with destructive changes in the lungs are the most drastic method is
surgery. Signs of bleeding is a discharge of blood trickle while coughing. Blood red,
sometimes dark black folds (clots), sometimes with the addition of sputum. In such
patients, side pain, feeling of fullness in the chest, shortness of breath. When listening to
the wheezing of the lungs. So sick - tourniquets on the lower limbs to reduce pressure in
the pulmonary circulation, a solution of atropine 0,1% - 1 ml, a hemostatic agent, an
antihistamine, connect the single-group blood (fresh). Hospitalitynet to a specialist unit.

Abdominal bleeding.
Causes: ulcers, esophageal varices, ruptures of the liver, spleen, erosive gastritis, gastric
ulcer of colon, ulcerative colitis, intestinal tumors, ulcers diverticula. The most common
cause (60%) are gastrointestinal bleeding, and from this category I place bleeding from
esophageal varices.
The mechanism of bleeding due to blood clotting disorders and hormonal reaction, ulcers
submucosal and mucous membranes of the stomach, 12 duodenal ulcer. Among patients
relative prosperity appears severe weakness, dizziness, noise in the head, ringing in the
ears, the appearance of spots before the eyes, cold clammy sweat. The more bleeding, the
the signs of intense. The appearance of vomiting blood, tarry stools present with bilateral
signs of gastrointestinal bleeding. The vomit may be red blood or like "coffee grounds".
Red blood appear, as a rule, when bleeding from veins in the esophagus or perforation of
the stomach. The color of "coffee grounds" in perforation of the duodenum 12. Loose
stools in dark cherry color is when erosion of the vessels of the colon; tarry stools
bleeding from the small intestine. If the stool is black framed, it is bleeding slightly.
Intra-abdominal bleeding occurs after trauma (penetrating) through and not through the
injuries, the compression of razmotreni fabrics falling from height (Katerina), powerful
blows to the stomach. Clinic will depend on the damaged organ and the intensity of
bleeding in the abdominal cavity. Common symptoms: severe weakness, dizziness, noise
in the head, tinnitus, cold clammy sweat, tarry stools, shortness of breath, vomiting
blood, lower blood pressure and CVP, tachycardia.

The concept of fainting, collapse, shock, coma, causes.

Fainting is an acute vascular insufficiency with a sudden short-term loss of

consciousness due to acute deficiency of blood in the vessels (spasm) of the brain. The
reasons may be a sharp change in body position (for example, sharply raised his head in
bed), the effect of negative emotions (stress, injection), which leads to a sharp decrease in
the tone of small vessels (arterioles, veins, capillaries), their expansion and overflow with
blood. More often, the vessels of the abdominal cavity expand and blood from the head
flows into the abdominal cavity, arterial and venous pressure decreases.
  Fainting develops suddenly. There is tinnitus, “flies” in front of the eyes, weakness,
dizziness, pallor, lethargy, loss of consciousness. The man is falling. Against the
background of pallor, cold, sticky sweat, the pulse is frequent, hardly detected, blood
pressure decreases. Fainting from a few seconds to 10-30 minutes. Help: for the flow of
blood to the head, it is lowered, and legs are lifted, tight clothes are released, the temporal
region is rubbed, and ammonia solution is sniffed on a napkin. Caffeine is injected
subcutaneously, Cordiaminum / muscle, mesatone. After regaining consciousness they
give warm tea.

Collapse - inhibition of the sympathetic and increased tone of the parasympathetic

nervous system (vagus nerve), while the capacity of the vascular bed decreases, which
leads to less inflow of venous blood, cerebral blood flow of the cardiac output. The
reasons may be the use of drugs, local anesthetics, ganglion blockers, drugs that lower
blood pressure, conducting epidural anesthesia.
  Clinic: general weakness, nausea, vomiting, dizziness, cold, sticky sweat, decreased
blood pressure, frequent weak pulse. When there is a loss of blood, consciousness loses
shock.
  Help: the patient is lowered his head, raised his legs. The person is sprayed with cold
water. Stop administering anesthetics. A 10% solution of cordiamine 25% 0.5-1 ml is
introduced 10% caffeine solution 1-2 ml 1% mesatone solution 0.2 ml 0.1% adrenaline
solution 0.5-1 ml. In severe cases, reopoliglyukin 200-400 ml is connected, hormonal
preparations - hydrocortisone 3-5 mg / kg, prednisone 0.5-1 mg / kg. If the condition
does not improve, this condition is referred to as shock.

Shock is an extreme state of vital functions of the body that occurs as a result of exposure
to extreme strength and duration of action, characterized by external and internal
disorders, as well as a complex of disorders of physiological systems, primarily blood
circulation and central nervous system.
  The shock is based on absolute hypovolemia (the release of blood or plasma beyond the
vasculature - bleeding) or relative hypovolemia (deposition of blood in the peripheral
vessels as a result of bacteremia or toxinemia), as well as vasodilation, which leads to
cardiovascular failure or the so-called minor syndrome ejection. The rush of blood to the
left half of the heart is reduced and the syndrome of small ejection is a common sign of
all critical conditions, including traumatic ones, in particular with bone fractures,
extensive burns, injuries of internal organs, blood loss.
  Therefore, the term “shock” is a critical condition, the general sign of which is
hypovolemia. Acute bleeding is one of the important factors contributing to the
development of shock during injuries. Blood loss affects the volume of blood in the
veins. Venous vessels adapt quickly, but their function is depleted even with a loss of 5-
10% of BCC, so blood supply to the right heart is reduced. The heart tries to compensate
for this condition by tachycardia. In the mechanism of development of traumatic shock, a
certain role is played by damage to vital organs and impaired function. So, an intestinal
injury leads to intoxication of the body. The rapid penetration into the blood of its
content and bacterial aggression of microflora complicate the condition of the wounded.
Injuries to the chest are usually combined with damage to the heart, lungs, large bronchi,
accompanied by a violation of the respiratory and circulatory functions. The function of
the nervous system is also disturbed.

Phases and signs of shock.

In the pathogenesis of shock there are two phases: erectile and torpid.

Erectile phase is the excitement phase, - a very short time. It lasts from 3 to 30 min and
therefore often not recorded by the medical staff. General condition affected in this phase
are relatively satisfactory, consciousness is not disturbed; characterized by excessive
mobility, preravista speech, agitation, restless glance. The skin is pale. Sometimes it may
be congestion, in which the skin is covered with perspiration. The blood pressure in the
normal range or slightly increased. Sometimes there is hypotension. The pulse is often
slow but can be accelerated up to 100-110 in 1 min Breathing frequent, superficial.

Torpid phase - the phase of oppression. Depending on the severity of the disorders of
Central nervous system function, hemodynamics, systolic pressure and pulse there are
four degrees torpid phase of shock.

Shock I degree (mild) often occurs as a result of isolated injuries of moderate severity
and loss of 500-1000 ml of blood. The overall condition of the wounded is relatively
satisfactory. Observed moderate mental block. The skin is pale. Pulse is 100 in 1 minute,
satisfactory (weak) filling and voltage. Blood pressure stable, is 100-95 mm Hg. article (a
13.3 a 12.7 kPa). Body temperature in the normal range or slightly reduced. The
prognosis is favorable.

Shock II degree (moderate) develops in numerous injuries and blood loss, up to 1000-
1500 ml. the Overall condition of the affected heavy, orientation, and consciousness is
not impaired. The skin is pale, the mucous membrane of the lips cientifica. Determined
mental retardation. Pulse 110-130 in 1 min, weak filling. The maximum level of blood
pressure - mm Hg 90-75. article (12-10 kPa), is unstable. Characterized by oliguria. In the
case of carrying out complex activities antishock therapy, the prognosis is favorable.

Shock III degree (severe) occurs due to severe damage by splinters of mines of the
extremities, chest, abdomen. The blood loss reaches about 2000 ml. the Overall condition
of the wounded heavy. There has been a marked mental retardation, and sometimes
stupor. The skin is pale, with a cyanotic shade, can be covered with drops of sweat.
Mucous membranes are dry. Occurs hypothermia, lack of exercise, reduced tendon
reflexes, disorder of the urinary functions of the kidneys (oliguria, and more - anuria).
Pulse - 120-160 in 1 min, weak filling and voltage. Blood pressure - 75 mm Hg. article
(10 kPa). His breathing is shallow. If time does not hold complex antishock measures -
the prognosis is poor.

Shock of the VI degree - a terminal state, which is divided into an antagonal, agonal
state and clinical death - is characterized by an extremely serious condition of the victim.
Consciousness is absent; the skin is cyanotic, cold, covered with a sticky sweat; the
pupils are dilated, almost do not respond to light. Speech agitation, involuntary urination
are sometimes possible. Pulse on peripheral vessels and systolic blood pressure are not
determined. Extreme shock can lead to clinical death. With combined radiation injuries,
the frequency of traumatic shock increases. This is due not only to the severity of the
combined injury, but also to the peculiarities of the development of pathophysiological
changes in the body.
  The clinical picture of shock. At first, in the effective phase, while maintaining
consciousness, when the victim is worried, sufficient pressure is maintained. The skin is
pale, limbs are cold. The pulse is frequent, threadlike. Then, blood pressure drops
sharply, urine volume decreases (normally 1 - 1.2 ml per 1 min). The condition of the
victim worsens and the prognosis worsens if not eliminated:
- hypovolemia;
- respiratory failure;
- bleeding;
-pain syndrome.

When defining a stage of shock you should use such simple techniques:

1. Measurement of blood pressure. With systolic pressure less than 60 mm dramatically

reduces the blood supply to the brain. So pressure measurement is insufficient to
understand the hemodynamics.

2. Determining the color and temperature of skin. These figures give a glimpse of the
peripheral blood flow. Capillary refill is determined by pressing on the nail phalanx of
the thumb, which initially becomes pale and quickly turns red if the clicking to stop. The
filling time of the capillaries of the nail bed after compression normally takes no more
than 1-2 s, when the shock is greater than 2 s.

3. Determination of the severity of the shock using the shock index (the index Allgower).
Shock index (AI) is the ratio of heart rate to systolic blood pressure.
Providing pre-medical help is that first of all it is necessary to eliminate the effect of
traumatic agents, or of factors contributing to the development of shock. For example, the
victim should be removed from under the rubble, to stop external bleeding (to impose a
pressure bandage, tourniquet) on the wound aseptic bandage, to introduce analgesic
(promedol, etc.). In the case of threat of occurrence of asphyxia is to remove the cause,
which may lead to its development (to clean the oral cavity, to restore the patency of the
upper respiratory tract), enter the S-shaped tube, or duct, to carry out the immobilization
of a limb, apply an occlusive dressing if the damage to the chest and only then to
evacuate the injured to hospital.

Materials for self-control:

1. In which case you can do without the tourniquet?
1. While small blood loss.
2. Open fracture with bleeding.
3. Crushed limbs.
4. Traumatic amputation.
5. When hemorrhage, which threatens the life of the victim.

2. What is not a disorder of consciousness?

1. Shock.
2. The stupor.
3. Stupor.
4. Coma.
5. Faint.

3.Dorucena help with nosebleeds consists of the following activities except:

1. Providing the victim the prone position.
2. Cold to the area of the nose.
3. The pinning of the wings of the nose to the nasal septum.
4. Introduction to anterior nose with a cotton swab soaked in a solution of hydrogen
peroxide.
5. Providing the victim a semi-sitting position.

4.External bleeding is not true:

1. Bleeding in the joint.
2. Bleeding from the nose.
3. Krovotechenie from the stomach.
4. Bleeding from the urinary organs.
5. Bleeding from the back passage.

5.What is the primary symptom for the diagnosis of circulatory arrest?

1. Absence of pulse on carotid arteries.
2. No pulse on arteries of the upper limbs.
3. The lack of heart rate.
4. The lack of breathing.
5. The lack of reaction to light dilated pupils.

6.The patient as a result of fracture of the lower jaw, there was abundant arterial bleeding
from the facial and temporal area. Your actions:
1. Finger compression of the common carotid artery.
2. The imposition of a pressure bandage.
3. Treatment of the wound with hydrogen peroxide.
4. To ask the victim, while it the ambulance arrives.
5. To call the doctor.

7. The victim on the street suddenly started bleeding from varicose veins in the lower leg
area. Your actions:
1. The imposition of a pressure bandage.
2. The tourniquet on the thigh.
3. Flexion of the leg at the knee joint.
4. Ask the victim until the ambulance arrives.
5. To call the doctor.

8.The basic characteristics of venous bleeding:

1. Compared to the slow nature of the bleeding.
2. Blood oozes through the wound.
3. The pulsating nature of the bleeding.
4. Bright red blood pours out.
5. Direct priznakov venous bleeding no.

9.The basic characteristics of arterial bleeding:

1. The pulsating nature of the bleeding.
2. The dark color of blood pours out.
3. The color of blood does not matter.
4. Compared to the slow nature of the bleeding.
5. Blood oozes through the wound.

10.The victim is under the car, clear. There is an open fracture of the forearm, the wound
pulsating stream of blood comes out. Your priority action:
1. To stop the bleeding.
2. To get the victim with the help of a present from under the car.
3. Observe the victim while awaiting the ambulance.
4. Ask the victim until ambulance arrives.
5. To call the doctor.

Литература
Основная:
1. Материалы подготовки к практическим занятиям.
2. Домедична допомога (алгоритми, маніпуляції): Методичний посібник /
В.О.Крилюк, В.Д.Юрченко, А.А.Гудима [та ін.] – К.: НВП “Інтерсервіс”, 2014. - 84
с.
3. Тарасюк В.С., Матвійчук М.В. Паламар М.В., Поляруш В.В., Корольова Н.Д.,
Подолян В.М. Малик С.Л., Кривецька Н.В. Перша медична (екстрена) допомога з
елементами тактичної медицини на до госпітальному етапі в умовах надзвичайних
ситуацій. – К.: Медицина, 2015
Дополнительная:
1. Стандарт підготовки І-СТ-3: Підготовка військовослужбовця з тактичної
медицини (видання 2). К: “МП Леся”, 2015. – 148 с.
2. Електронная версия Стандарта подготовки І-СТ-3: Подготовка
военнослужащего с тактической медицини (издание 2) –
http://www.medsanbat. info/standart-pidgotovki-i-st-3-vidannya-2-pidgotovka-
viyskovosluzhbovtsya-z-taktichnoyi-meditsini/ (название с экрана).
3. Видео сюжеты:
www.youtube.com/playlist?list=PLGVZyDkrMM_QrjemyQ5j56G8sQolHsYoG

Guidelines prepared by
PhD in medical sciences A. Levkov